Fixed Fee Collection Service: Order Form

Company Information:

Company Name (Legal): (required)

Company DBA Name: (optional - Required only if different from legal name.)
(If Doing Business As (DBA) name is provided, it will appear on the demands)

Attn: (optional)

Address: (required)

City: (required)

State: (required)
AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingPuerto Rico

Zip: (required)

Phone (required)

What is your Industry (required)
—Please choose an option—MedicalDentalEducationEnergyFinanceAutomotiveGovernmentConstructionLegalTechnologyUtilityOther

Primary Contact:

Your Name: (required)

Your Email: (required)

Settle in Full Authority:
Kinum always attempts to recover 100% of the amount owed from the debtor. However, sometimes a debtor agrees to pay a lower amount during Collection Calls (Step 3) to settle the case. We recommend 80%. You authorize Kinum to settle any accounts at or above the Settle in Full Authority percentage rate below.
100% - (Only settle for full amount)90% - (OK to settle at or above 90% of Amount Due)80% - (OK to settle at or above 80% of Amount Due)70% - (OK to settle at or above 70% of Amount Due)60% - (OK to settle at or above 60% of Amount Due)

Collection Calls Service Fees:

Kinum's Commission Fees:
40% : Any Age , Amount $100 and above
50% : Any Age , Amount less than $100
50% : Legal
50% : Mail Returns

Service Options

Transfer Preference:
All accounts which remain unpaid after Collection Demands (Step 2) service can be automatically transferred to the next step, Collection Calls Service (Step 3), after waiting for 15 days. We recommend "Yes", but its your choice.
YES - Transfer all accounts automatically after 15 daysNO - I will manually select and transfer accounts

Credit Reporting:
If you select "Yes", you authorize Kinum to report Step 3 debts to the credit bureaus on your behalf. You agree to abide by all rules set forth by the Fair Credit Reporting Act (FCRA).
NO - Do not report to Credit BureausYES - Please report to Credit Bureaus

Terms and Service Agreement

I have read and accepted the Privacy Policy & Terms of use

I have read the Service Agreement and e-Signing it by checking the box

Your Signature:

Please sign with touchpad or touchscreen: